Over 1.7 million uninsured pregnant women face the confusing, time consuming, and often exhausting task of enrolling and participating in Medicaid, WIC, managed care plans, prenatal care and other community programs; all embedded in a fragmented, costly, inefficient non-system of care. These problems are especially problematic as low income women have a higher prevalence of depressive disorders, are more likely to have chronic health conditions and engage in poor health behaviors, and are more difficult to engage and retain in services. In most states, Medicaid also provides enhanced prenatal and postnatal services (EPS) to augment prenatal care with risk assessment, care management, referrals, and transportation; services primarily offered in the home. However, in Michigan, only 30% of eligible women are risk screened, enrolled, and/or choose to participate in EPS. Given US health reform efforts to expand access to care and increase perinatal home visiting programs, there is a critical need to fix the policy, community, and organizational context in which care is delivered. Utilization of the Chronic Care Model (CCM) has proven effective addressing similar issues, but has not been used as an organizing framework for a population of Medicaid-insured pregnant women and their newborn infants. The objective of this application is to demonstrate and disseminate a system of care for Medicaid-insured women and their infants in the second largest Michigan community with one of the fastest growing poverty rates in the US. We aim: 1) to use the CCM to operationalize and implement a population focused, Perinatal System of Care for Medicaid insured women and their infants; 2) to implement and examine the population impacts of a community system of care on health care utilization, costs, and health outcomes; and 3) to refine the model, based on research findings, and disseminate for other communities, Medicaid policy makers and others. This project uses a population approach and it will be accomplished in collaboration with Medicaid. At the completion of this project, we expect to have a well-tested Perinatal System of Care that improves processes of care and health outcomes, is cost efficient and can be used to assist Medicaid policymakers make smart up-front investments. We will have a Perinatal System of Care Tool Kit, a compendium of resources for implementation and, by partnering with the Michigan Department of Community Health, will have disseminated the model to other communities and national audiences. PUBLIC HEALTH RELEVANCE: The proposed project will develop and test a redesigned community Perinatal System of Care, based on the Chronic Care Model, for Medicaid-insured pregnant women and their infants. The features of the redesigned system of care will address coordination of care and early engagement and retention of women in prenatal/postnatal care, especially for those women who are harder to reach and whose participation may be complicated by stress, depression and other mental health related issues.